from the Association of American Physicians and Surgeons

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Digital panacea is fiscally disastrous, clinically dangerous

While advances in technology—eagerly adopted by doctors and hospitals—are often blamed for high medical costs, there is one type of technology that will supposedly save billions once we “invest” billions in it and force it on supposedly recalcitrant, technophobic doctors and hospitals: health information technology (HIT), including the electronic medical record (EMR) and computerized physician order entry (CPOE).

The “stimulus” package provides between $44,000 and $64,000 for physicians who acquire an EMR and demonstrate “meaningful use.” However, “the price is dwarfed by the problems [an EMR] causes the office,” stated Evan Steele, CEO of SRS Soft, which provides a less complex alternative. If a specialist who bills $750,000 a year loses 5% of her productivity dealing with the computer system, she loses $162,000 over 5 years (Physicians Practice, April 2009).

Even the vaunted Veterans Administration system has major problems. An 8-year, $167 million project was not able to develop acceptable scheduling software. The military’s AHLTA system is so slow, unreliable, and cumbersome that clinicians spend 40% of their time inputting data, causing a “near mutiny” (CPR #172, 4/3/09).

For ₤12.7 billion the UK still does not have a national health information technology system, but rather an HIT quagmire, some of it caused by U.S. HIT vendors, writes Dr. Scot Silverstein to the Wall Street Journal.

The province of Ontario just created a new agency, eHealth Ontario, to replace Smart Systems for Health Agency, which spent $647 million without showing any noticeable results. The new agency is supposed to provide EMRs for all citizens by 2015. The province has just hired a consultant to examine whether eHealth Ontario is spending too much money on consultants (Canada Free Press 6/9/09).

In the U.S. also, “most big health IT projects have been clear disasters,” says Dr. David Kibbe, senior technology advisor to the American Academy of Family Physicians. And it’s not just the money.

One U.S. pharmaceutical data base found 43,372 medication mistakes, or about 25% of the total reported in 2006, that involved computer technology: flaws in data entry, inadequate software, and confusing screens. In 2006, Children’s National Medical Center in Washington, D.C., found an eightfold increase in dosage errors for high-risk medications (Terhune C, et al., Business Week 4/23/09).

A 2005 study by University of Pennsylvania sociologist Ross Koppel found 22 circumstances in which the software boosted the probability of error. Doctors also suffered from “alert fatigue” from endless false alarms about minor drug interactions.

“If drug companies sold products with this quality level,” states Dr. Scot Silverstein, “it would be a scandal” (Forbes 5/11/09).

Potential benefits have been greatly exaggerated. Large randomized controlled studies in both the U.S. and Britain have found that EMRs with computerized decision support “did not result in a single improvement in any measure of quality of care for patients with chronic conditions including heart disease and asthma” (Washington Post 3/17/09).

What gives the U.S. government the right to take taxpayers money (or money the government prints) to bribe doctors and hospitals to keep records in a dangerous or inefficient manner? Nothing said here will stop these transactions, however. Very few physicians are finding EMR to be helpful. Many consider it dangerous to patients. Nearly all agree it is wasteful and time-consuming. It doesn’t matter. Either we accept these improprieties or mount a legal challenge. What gives the U.S. government the authority to mandate how doctors must keep their records. In a free society envisioned by the founders, citizens were free to decide any such issues for themselves. Physicians are NOT against innovation. Simply witness the advanced medical technology in the last few decades. If EMR was truly cost-effective and beneficial, it would NOT require huge government bribes to hospitals and physicians, which is unlawful interference with the practice of medicine, and, without a doubt, an infringement of that time-honored practice of physician-patient CONFIDENTIALITY. This is a huge government sponsored HIPPA violation. We need some serious lawyers to bring charges, fines, etc.!!

America’s government was founded on the principle of individual rights with its purpose cleaarly stated in the declaration of independence “that to secure these rights governments are instituted among men deriving their just powers from the consent of the governed”. Government interferrence in any activity that does not violate the rights of another individual is a violation of the purpose of government. Every such action is destructive and is properly understood as evil. Until MD’s in particular and people in general understand these fact no appeal to the expensive nature or the impractical nature of government interferrence will carry the day and free MDs and all productive men from these acts of tyranny.

I belong to AAPS and support many of your positions. But you are simply wrong on electronic medical records. I have used one in my solo family practice for twenty years, and I would never want to practice without one. In fact, my office is in the process of upgrading hardware and software now – WITHOUT any stimulus money, since I don’t accept Medicare or Medicaid. Why am I investing $25,000 into my practice? Because it makes me money, it saves me time, it reduces errors and it improves the level of care I provide my patients. Are there dangers in accepting government money for a computer system? Of course there are. The government wants to mine the data for trivial errors that they can fine us for. But it is embarrassing that physicians are the last profession to adopt computer technology. My veterinarian was doing it before I was. Our accountants have been doing it for decades. We look foolish objecting to computerization when the rest of the world did so years ago. I think we need to advocate for PRIVATE computer technology that benefits our patients and our profession – and to hell with the government and the insurance companies.

the problem still is the government is using enticing methods to push physicians to use emr. i understand that some physicians would difinitly do better with the emr. that does not mean everyone should. we can not learn anything from individual experiencebut we need to learn from system-based healthcare that impleminted emr for sometime e.g. VA system. i consider myself very good with tech and i liked the VA emr very much when i was working there and i consider it alot better than the other i used afterwords but there inherited problems with the emr that are different than what we used to see.

in anyevent, i emplimented one of the emr in 2004 and i personaly liked but i discontinued it in2004 because:
1. i was forced to let good nurses go because they could not adopt and i stuck with bad ones because they did fine with the system
2. dataentery cost
3. patient’ perception when you work with gadgets infront of them
4. colleages’ perception of the note

whatever we chose it:
1. it should not be forced for enticed
2. one size will not fit all without high compromises
3. competition is the key in any services
4. no for central power because it could offer a quick solution today but surely followed with corruption and bad un-intended results
5. the consumer (in this case the physician) knows what is going to work
6. what works for certain servises e.g. dermatology does not necessary works for medicine

Don’t forget the unsupported costs of upgrades/revisions, liability
for loss of information or loss of privacy from security compromises
at any level, loss of productivity from breakdown and upkeep; the list
is as long as any problem you have ever had with a computer or
network. The blandishments will be dwarfed by the costs and grief in
no time flat. Zvi

Those physicians who do have the savvy, enthusiasm, staff and support for an EMR should be free to get one. However, it’s clear all the HIT companies in the world cannot support every physician office in the country. Without proper support, HIT can become a disaster.

The evidence that EMR actually improves patient outcomes in ambulatory settings is equivocal, it should be remembered, and one should beware vendors and pundits who cherry-pick from the literature about how much money and lives clinical IT will save. Experiences in other countries suggest that the exuberance for HIT as a panacea is based on myths.

I was able to record on tablet PC (in Excel) like on a manila folder with, script to text, 4 years ago.
It was just just a little more weight and distraction from eye contact. The major tech problem was merging record lists between computers (one used by assistant for vitals, etc).

However, ease of abuse by gov. raiders, even though I was careful not to go online and used paper ins claims (preserved “Country Doctor”exclusion from HIPPA), privacy,
decided me to simply record on a paper matrix for PATIENT recall (and keep a copy). It is easier to record and recall (even when the patient doesn’t remember to bring the record).

Future use, same matrix of Patient’s Record but on tablet PC with flash drive for savvy patient use, awaits more trustworthy government. Cash-only practice and sending patients with their own records (circled Advice) really simplifies and economizes to better enjoy the Patient-Physician Relationship.

Thank you for all the references on this subject. It is amazing that the VA system is being touted as a model medical system based on its adoption of an EMR. Talk about not seeing the forest for the trees.

I am happy that Dr. Mohr has exercised his liberty and freedom to
voluntarily adopt an EMR for his practice. I am also pleased that he
is happy with the performance of his system. He apparently feels
considerable pride in “investing $25,000 into (his) practice” (without
government reimbursement) to upgrade his system. I would never
want to infringe upon his right to run his practice the way he wants.
Dr. Mohr also believes that his EMR makes money, saves time, reduces
errors, and improves his level of care. I congratulate him for those
desirable accomplishments. In the debate over EMR’s, these claims
by proponents of EMR are ubiquitous, but so far, I have seen very little
evidence basis to substantiate these claims. And it is certainly beyond
the scope of my response, nor is it my desire, to ask Dr. Mohr to do so.
It is wonderful for Dr. Mohr that EMR works for him. I do not believe EMR
would work in the same way for me in my solo Otolaryngology practice.
(It should be apparent at this point that I am in agreement with the AAPS
opinion on EMR/HIT.) I would never want to infringe upon any other
physician’s liberty to use EMR in his/her practice. Dr. Mohr would no
doubt object to the government passing a law or regulation making it
illegal for physician practices to use EMR, just as I object to a law or
regulation forcing me to adopt EMR for my practice.
Finally, Dr. Mohr resorts to a purely inappropriate emotional argument in support of EMR by expressing his opinion that “it is embarassing that
physicians are the last profession (sic) to adopt computer technology”.
I am not embarassed about my personal choice to refuse to adopt
computer technology (in the form of EMR) for my practice. I am sorry, but not responsible, for Dr. Mohr’s sense of embarassment. Dr. Mohr,
please do not feel embarassed on my behalf.
I thank the AAPS for illuminating and substatiating the down-sides to HIT/EMR. It would be nice if the proponents of this technology could
support with data all of their claims of the advantages. It would also be proper for the government to respect my freedom to keep my records in the form of my choosing.

I have worked in the medical, legal and med-legal industries for over 20 years in various capacities, to include research, and publishing, and HIPAA consulting, and I have a solid background in IT, and I have yet to see an electronic or computer based protocol that is hack proof let alone 100% error free. EMR may have it’s advantages, and they are very few (unless you are talking about what I like to call a homogenized practice – think same old, same old, which very few are and can ever hope to be), in the same vein that I would not want my medical records or those of my family, being sent overseas to be done, I most certainly would not want them entrusted to a computer technology that cannot give me assurances that are verifiable when it comes to the security of the record and its overall accuracy, and EMR cannot do that.

EMR cannot pick up the errors that can easily be made the way a human being can, nor can EMR fix those errors. It is seriously beyond me how any provider that has a level of conscience, professional ethic, and morality could consider turning their practice over to what amounts to dodgy/wonky A.I., on its best day. I’ve read everything that I can get my hands on with respect to EMR because of the impact it has not only on my clients and business, but the impact it has on me personally with respect to my own health care and that of my family, and thus far it has been my experience that the providers who are clamoring to incorporate this into their practices are doing it blindly and without considering the exorbitant costs that would be involved in creating a workable infrastructure within their practice that could provide their patients with 100% security and accuracy, which cannot be done at this point with ANY of the EMR technologies available on the market. The providers that are doing this, it has been my experience, have learned to regret their choices because financially any immediate gain that they might see is soon lost when productivity comes to a screeching halt when the system goes down and like all computer systems, it will go down. Clients that have come to me after implementing EMR and having a near mutiny on their hands, have all ended up saying the same thing, that anything too good to be true usually turns out to be just that, too good to be true and a regret and not just from a fiscal perspective.

Moreover, having been in the field as long as I have been, I have found that many of the vendors that do provide EMR with some kind of adjunct service of proofing or amending the record that is initially captured on the EMR, is typically sending this part of the work overseas, so again it brings up the question of security, given that overseas folk do not have the same laws that we do, nor feel any compunction to adhere to ours, and simply put, accuracy of the record, and if you have seen any of the work that comes out of these operations, and I have, it’s a mess and will make your eyes bleed.

The government is on a slippery slope with this for a variety of reasons but the most salient is that EMR, in the way that they are attempting to implement it, flies in the face of HIPAA and frankly nothing that has been proposed thus far, and given what I have seen with EMR, makes me feel that I would want to circle the wagons around EMR as being the end all and be all.

Also insofar as the VA being touted as the medical model for anything except serious considerations of gross negligence, excuse me, but am I the only who remembers what happened with the VA back in 2006 with something like 26 million records being compromised and hacked? Is the VA we are talking about the same VA who has scored no higher than a D grade except ONE TIME when they got a C, when being graded for the annual federal security report card? Oh my, for sure THAT is the medical model that all practices should strive to measure up to, I’m thinking not so much, unless you enjoy, as a provider, being pegged with impossible malpractice insurance premiums assuming the insurance could be gotten at all, and enjoy being trotted into court.

It is insulting to me given my brother is a retired Marine, that the agency responsible for providing him with his health care, benefits, and the like, is getting D grades with respect to the security of his records. I think the magnitude of what happened in 2006 is just a glaring example of the risks that have not been adequately thought out with respect to EMR, security of data, and the like, and frankly I don’t see that as being anything but one more impediment in what is being attempted here, and as far as what people are trying to achieve with respect to medical care, it certainly, in my humble opinion, goes against what most doctors have promised to do with their skills.

Bottom line, Primum non nocere or primum nil nocere, MUST and HAS TO extend beyond the patient, it MUST and HAS TO extend to the obvious extension of a patient, and that obvious extension lies in that patient’s medical record, the data that speaks for a patient, when they might not be able to speak for themselves.

First let me say I am glad there are others who are concerned about security and Medical records. Susan Rojo is completely right when she says she has yet to see a system that cannot be hacked. You will recall all the incidents in which the Department of Defense had it’s systems hacked over the years (they don’t make them public anymore). These were all done by high school kids…just think what a college grad with a degree in computer science could do!
Imagine the dollar value of being able to data mine from a national health data base. Drug companies would pay big bucks for this (a possible solution for our national debt here Ha ha) as would nursing homes, equipment makers etc. How about the Enquirer paying a good chunk for the complete medical record of Michael Jackson. The potential is endless. And as Ms Rojo says we have good evidence that the data is no more secure than the people who have access to it. I was one of the veterans who had his medical record in the laptop that was stolen (or was it sold) from the car seat of the VA employee who decided to take the computer home with him. I am still waiting for the identity theft to show up on my credit.
Having worked at the National Security Agency (that’s right, I was a spy before I became a doc) I have a little different way of looking at security and communication systems, which is what we are really looking at here. The Internet is an “open broadcast” form of communication (it is not a point to point connection as so many of you would like to believe) and as such is the most vulnerable form of communication to interception. If it can be intercepted, it’s encryption can be broken or the “backdoor” access that is built in to many systems is findable. Having such sensitive data “out there” circulating through multiple nodes is risky. If not for identity theft, how about things patients tell you that they wouldn’t want their kids, spouses and neighbors to know about. Patients tell us things about their lives that no one else (including their insurance company and the government) need to know about. Will they begin to omit critical information if they know it is going into a data bank that is potentially accessed by hundreds of people (read that as “potential leaks”). Will we need to keep a separate “in-house” addendum of information the patient wants “absolutely secure”?
First let’s ask ourselves some important questions. The government says they want to cut health care costs by instituting a standardized EMR. Now REALLY, when was the last time the government wanted to help YOU make money? NEVER you say? Well then do you suppose that what they really mean is “We (the government) want to save money by shifting costs to the doctors via forced IT. And we think we can save money by linking all of the personal health data into one big data base. We will not only be able to manipulate payments to doctors, we will be able to send out personal letters to patients advising them on specific health care issues (maybe even “time for your ‘end of life’ planning).”
I will admit that there are some potential great social advantages to having a national health data base such as early identification of infectious disease outbreaks, environmental effects etc but these need not be tagged to personally identifiable information and the complete contents of the medical record…which is where I believe we are eventually heading when they say they want all the patients doctors to have access to the other doctors notes (and MAN what a liability issue “And tell me doctor did you read ALL of the notes from ALL of the doctors before you ________!”
I will likely be squeezed out of medicine if I don’t retire first. I have already refused to give out my patients social security numbers for the state’s required melanoma reporting unless I have received prior approval from the patient. I was surprised to find out that pathologists and oncologists have been giving out this information WITHOUT NOTIFYING PATIENTS for years. To me this is a breach of doctor/ patient priviledge. The government should be asking the patient to participate not putting the doctor in the position of “I vas only followink orders”. In my office we have taken the oath of confidentiality seriously and have released information only with the patients permission. When the government begins to believe that they are in charge and make us their unwitting snitches it is time to wake up and speak up.